View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Patient Education and Counseling 89 (2012) 267–273 Contents lists available at SciVerse ScienceDirect Patient Education and Counseling jo urnal homepage: www.elsevier.com/locate/pateducou Communication Study How the doc should (not) talk: When breaking bad news with negations § influences patients’ immediate responses and medical adherence intentions a, a b,c Christian Burgers *, Camiel J. Beukeboom , Lisa Sparks a Department of Communication Studies, VU University Amsterdam, The Netherlands b Health and Risk Communication, Schmid College of Science, Chapman University, Orange, CA, USA c Chao Family Comprehensive Cancer Center/NCI Designated, Public Health/Medicine, University of California, Irvine, USA A R T I C L E I N F O A B S T R A C T Article history: Objective: We investigate the role of specific formulations in a doctor’s bad news delivery. We focus on Received 3 April 2012 the effects of negations and message framing on patients’ immediate responses to the message and the Received in revised form 16 July 2012 doctor, and long-term consequences including quality of life and medical adherence intentions. Accepted 9 August 2012 Methods: Two lab experiments with 2 (language use: negations vs. affirmations) Â 2 (framing: positive vs. negative) between-subjects designs. After reading a transcription (experiment 1) or seeing a film clip Keywords: (experiment 2), participants rated their evaluation of the message and the doctor, expected quality of Breaking bad news life, and medical adherence intentions. Negations Results: Positively framed bad news with negations score more negative on these dependent variables Framing than positively framed affirmations (both experiments). For negatively framed negations, these results Doctor–patient interactions Medical adherence are reversed (experiment 2). Furthermore, the evaluations of the message (experiment 1) and the doctor (both experiments) mediate the interaction of framing and language use on medical adherence intentions. Conclusions: Small linguistic variations (i.e., negations vs. affirmations) in breaking bad news can have a significant impact on the health message, doctor evaluation and medical adherence intentions. Practice implications: Doctors should refrain from using negations to break positively framed news, and employ negations when breaking negatively framed news. ß 2012 Elsevier Ireland Ltd. Open access under the Elsevier OA license. 1. Introduction provider training as effective as possible, it is important to understand the factors that determine patients’ positive or negative Next to being excellent health experts, doctors need to be good psychosocial responses. communicators. Doctors deliver bad news to patients thousands of Yet, little is known about which specific elements make doctor– times during their professional careers [1]. For patients, receiving patient communication effective. Most studies on the required bad news is stressful in itself [2], but when doctors deliver the news formulation and style of doctor–patient interaction are descriptive, poorly, additional stress may be induced with negative effects on which means that they describe current practices in breaking bad patients’ health [2]. Furthermore, good doctor–patient communica- news (for overviews, see [11,12]). In fact, less than 2% of studies tion can predict medical adherence [3–6]. Thus, breaking bad news focusing on doctor–patient interaction explicitly address how to patients in an appropriate and effective way is a crucial task that doctors should formulate the information in such a way as to bears important consequences [7]. Fortunately, many studies increase patient satisfaction [12]. The rare studies that did address demonstrate that alerting and training doctors in these sensitive this issue adopted a general perspective, and showed that doctors’ communication issues greatly improves doctor–patient interaction general communication styles (e.g., comforting or empowering [8–10] and subsequent patient satisfaction [7]. In order to make styles) influence the effectiveness of doctor–patient conversations [7,13–15]. In the present study, we take a micro perspective by focusing on § The authors would like to thank Anouk van Berkel, Misha Naumovski, Nikki the actual words chosen by the doctor. Based on prior research, we Ouborg, Bram Schothorst and Sanne van der Velde for their help with the data argue that – next to the general communication styles employed collection for experiment 2. (e.g., direct/indirect, comforting, empowering [7]) – specific words * Corresponding author at: VU University Amsterdam, Department of Commu- may also be important predictors of the effectiveness of doctor– nication Studies, De Boelelaan 1081, 1081 HV Amsterdam, The Netherlands. Tel.: patient interaction. Breaking bad news to patients and their family +31 20 5987889. E-mail address: [email protected] (C. Burgers). members entails a highly sensitive communicative exchange in 0738-3991 ß 2012 Elsevier Ireland Ltd. Open access under the Elsevier OA license. http://dx.doi.org/10.1016/j.pec.2012.08.008 268 C. Burgers et al. / Patient Education and Counseling 89 (2012) 267–273 which small differences in word choices can make a big difference We expect that a positively framed message yield more positive [7,16–18]. After all, doctors need to balance their words carefully. responses than a negatively framed message, but that these effects They need to be truthful, but at the same time, they want to are moderated by the language used in the message (negations vs. preserve the hopes of the patient and mitigate the information. In affirmations). When negations are used to break news that is this balancing act, subtle differences in word choice may influence framed as relatively good (e.g., ‘‘not bad’’), patients are expected to a patient’s evaluation of the conversation and the doctor, which in more negatively evaluate the message (H1a), the doctor (H2a) and turn have potential long-term effects on medical adherence [19]. their expected quality of life (H3a) and to have lower medical A first aspect in message formulation is the framing used to adherence intentions (H4a), compared to when affirmations are deliver the diagnosis, which can be framed to emphasize either the used (e.g., ‘‘good’’). In contrast, when breaking news that is framed positive or the negative outcomes of a diagnosis. The relative as relatively bad and more mitigated language is thus appropriate, strengths of positive and negative framing of factually equivalent we expect these effects to be reversed (H1-4b). We expect the information has been studied with regard to the communication strongest effects of language use in positively framed messages, involved in health-related decisions, which has its conceptual because in these cases negations (e.g., ‘‘you will not die’’) imply the roots grounded in prospect theory (see [20–22]). These studies negative inference that the doctor has a more negative expectation show that individuals react differentially to information presented than the actual message conveys. in different frames. In the health domain, various studies show Furthermore, we expect the immediate responses to the occurrences of framing of health-related information [23–25] and message to be related to the more long-term outcomes. That is, their effects on patient perceptions [26–31]. With respect to given the link between patients’ impressions of the doctor–patient breaking bad news, a framing differences may refer to emphasizing relationship and medical adherence [19], we expect that the long- either the positive or negative aspects of a given diagnosis: given term effects of framing and language use on medical adherence the range of possible diagnoses, is the particular diagnosis intentions are mediated by the immediate evaluation of the presented as relatively good (positive frame) or relatively bad message (H5a) and the doctor (H5b). (negative frame)? An aspect that may moderate a framing effect [32] in the 2. Methods balancing act of breaking bad news is the actual words that doctors choose to formulate their message. Empirical evidence suggests 2.1. Design and sample for experiment 1 that doctors tend to mitigate their words when they have to deliver relatively bad news compared to relatively good news [13]. One A total of 100 US respondents participated in experiment 1, verbal strategy that doctors can use to mitigate information and to which had a 2 (framing of diagnosis: good vs. bad) Â 2 (language be polite is using negations (e.g., ‘‘this news is not good’’) rather use: negations vs. affirmations) between-subjects experimental than affirmations (e.g., ‘‘this news is bad’’; [33,34]). Indeed, 1 design. Participants were healthy volunteers and recruited in empirical evidence suggests that doctors frequently use negations forums on social network sites, such as Facebook, and participated when making diagnoses [35–38]. in an online experiment by clicking on a link. The average age was Using negations, however, may come at a cost, because 41.88 years (SD = 12.43). A large majority of participants (78.0%) negations may provide implicit cues about the expectancies of was female. the speaker [39–41]. For example, negations like ‘‘you will not die’’ may implicitly communicate that the doctor expected, or at least 2.2. Design and sample for experiment 2 considered, that the patient would die. Such inferences are not likely when